Fear Changes How Patients Move — New Research Chiropractors Need to Understand | #519

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are back with more research and this is a topic I love to talk about. It's about pain related fear, avoidance behavior, how people change what they do based upon fear. This ties into what we see every day in practice and it's where you and I as chiropractors can make a massive influence. It's going to be a brand new study we will touch on in just a moment. Before we do special shout out to my partners at Blue Honest Lasers $2,500 off their Pro VX laser, a fantastic full spectrum laser. I'll drop that link as a listener $2,500 off as well as Leander tables $1,000 off their series 950. I'm going to drop that link down in the show. Well, massive savings for you just for being a listener of this podcast through our partners. They support this podcast. Please go support them. And as I said at the top, today's episode is all about research. We're talking about pain related fear influences. Specifically, the title of this study was Task Specific Pain Related Fear Influences Lifting Biomechanics Differently in individuals with and without occupations involving repetitive lifting tasks. Man, that is a wordy title. But basically people that lift all day long, how do they change their behavior if they are fearful of hurting themselves? That's what this is about. So if you've ever watched a patient lift a light box and thought, are they really that stiff? Or you've thought, if avoiding spinal flexion were the secret to providing or preventing low back pain, wouldn't the people who lift for a living have the healthiest backs on the planet? Well, today's episode's gonna challenge a lot of your long held beliefs about lifting posture and fear. And this is a hyper practical episode because it relates really directly to what your patients and every human being on planet earth does every single day, which is bending, lift and move around in the real world. Now this study specifically looked at pain related fear and lifting mechanics in a pretty interesting way. They compared people who lift constantly at work versus those who don't. And what they found is one of the clearest demonstrations or research based outcomes. Or they found out that beliefs do change biomechanics. So the research team was in Switzerland and they started this study by asking a really simple but a massively important question. That question is, does fear of bending your back during lifting change how you actually move? And does that effect differ between people who lift at work and people who don't. Now we've known for years that people who have chronic low back pain often kind of stiffen up, they avoid bending, they change their movement even when they're asked to lift something super lightweight. And we've also seen this in healthy individuals that have no pain or no injury. They're just using protective strategies when they believe something is dangerous. And that's some key words there. When they believe it's dangerous. Because often these habits, so to speak, are applied when there's not a stimulus that's gonna cause pain. Right. And that's really where the belief aspect is really important. But here's the twist. We've never really examined whether these fear driven movement behaviors show up in people that actually do lift all day long. Postal workers, warehouse workers, delivery drivers, mechanics, pretty much the people who move heavy stuff each and every day. So this study set out to do a few things. One, compare the people whose job requires repetitive lifting, the lifters, with the non lifters, people who don't lift at work. And then they were looking at a variety of different, so to speak, outcomes or factors. One, pain related fear, excuse me. Two, general anxiety. Three, lifting with 11 pounds, lifting with 33 pounds, lifting and lowering. We're gonna get to that in a moment. And whether they had any past history of low back pain. So they used wearable sensors to measure the lumbar spinal range of motion. And then they used video analysis to evaluate the whole body lifting style. This is, this is cool stuff because they're actually utilizing what I'm gonna call technology. Again, you have to understand research is always a few years behind, meaning you have to submit a research paper with your ideas to hopefully get funding. Then the funding takes a while to come through, then you have to implement it, then you have to write it up and publish it. And it's why we don't often see research that is, you know, utilizing the technology that's available today is because it takes a long time to do this stuff. So this study is cool because they're using wearable sensors and they're using video analysis, which I thought was great. And this is a field based research project, so it's not just a tiny lab study. So they had over 155 healthy and pain free adults. And I'm gonna go through a few of their key findings. We'll highlight four of the key findings and we'll kind of talk about how this applies in practice, conversationally, et cetera. So key finding number one, fear reduces lumbar spine motion, but only in people who don't lift at work. So in non lifters, higher fear scores equaled significantly less lumbar spinal range of motion. That's really interesting. We'll come back around to it in a moment. Key finding number two, People who are lifters showed no change in lumbar spine motion even when they had higher fear scores. So the lifters actually scored higher on fear questionnaires but did not change their lifting biomechanics. Interesting there. Probably a little surprising. Key finding three, fear mattered more when the load was heavier. No surprise there. And during the lowering phase. So we'll come back around to that one as well. So this is why I love this study, because there were just so many things where I'm like, I would have, I wouldn't have thought that. And then key finding number four. Fear did not significantly change squat versus stooping lifting style. The whole body strategy stayed relatively constant. And the biggest changes happened, of course, in the lumbar spine. So, so let's break this down a little bit more. People who don't lift for a living, but believe lifting with a rounded back is harmful move with more perceived stiffness. They bend less with their spine throughout the lifting tasks. So their strategy, if you're a non, if you're non lifter, somebody who doesn't lift all day for work and you are kind of concerned about lifting something, you generally use less motion, you use more muscle contraction, you use more bracing and more guarding even when they were lifting something super light. So this supports a lot of earlier research studies that kind of build the cascade saying fear equals stiffness equals reduced lumbar motion equals increased spinal loading.

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So the question is like why, why don't, why don't the lifters show the same, the same posture, the same, same stiffening response? And the authors propose something important that even though the lifters are taught to lift with a straight back and avoid flexion, their real world exposure to lifting probably overrides that belief. They don't default to a kind of a stiffness Posture because it's just not efficient for them. Uh, they've developed what they refer to as functional confidence through exposure. I'll repeat that. Functional confidence through exposure. I love that those four words because I feel like that can just be like applied to any, any skill, literally. Email marketing, MD relations like functional confidence through exposure. Get out there, sports. Right? Get out there and do it and keep doing it. And chances are you will build a level of functional confidence. So you can think of it like this contextually. If your job requires you to bend and lift thousands of times per week, you're not going to stiffen up every time you lift and pick up a box, even if you think it might be dangerous. So the belief does not override the lived experience. So non lifters didn't have that experience. So their beliefs did override their movement patterns. And heavier loads did equal more fear based stiffness. So for that 15 kilogram box, 35 pound I think it was box, fear mattered more. And for the lowering phase, fear mattered more. So lowering equaled kind of less control when they were lowering the weight. And that increased the threat perception. So why does this matter for us? Probably some of this was really obvious, but let's dive into it. So you're working with people all day, every day that have spinal pain. And this study can be really a goldmine conversationally. From a clinical insight and conversation perspective. From Clinical Insights 1, it's just important, continuing to reinforce in your mind and with your patients that beliefs can change biomechanics, even in people that don't have pain, you don't need pain to move like you're injured, you just need fear. And this is where altered biomechanics have the potential to increase the likelihood of injury because you're not moving correctly, altered biomechanics, compensation patterns, et cetera. So really important. The second important clinical insight is that exposure builds confidence that we touched on. People who lift regularly don't utilize protective stiffness, even when their beliefs would predict that they would. So this reinforces that movement itself. The movement itself can be therapeutic. That avoidance reinforces fear and that gradual exposure builds resistance or resilience. Excuse me. And understanding that I think is critical when we think about patients and their rehab, right, their active care component, because I want to go through those again. Movement itself is therapy. We have to say the movement, the diagnostic can be the therapeutic, right? So watching somebody squat, that gives you information from a diagnostic perspective, but also that squat can be the therapy. Right? Avoidance reinforces fear behavior. So that grad number three the gradual exposure builds resilience over time. Really important when building a rehab plan. Another clinical insight that I gleamed from this was telling patients to quote unquote, keep their back straight, may reinforce harmful beliefs. So the occupational lifters in this study had sky high fear scores and most of that was probably due to their training around neutral spine and don't bend. Now, I'm not saying to be flippant about how you encourage people to lift safely, but you have to frame things in context because they don't have your patients, by definition, 99.9% of them don't have the education that you have. So choosing the words, your context and framing for how you go about rehab, for how you educate your patients is really important to, to how they translate that into their life. And the clinical insight number four that I took away was really that fear driven stiffness increases spinal load. So over bracing actually can increase the compressive forces and fatigue. So trying to use these protection mechanisms, they might be making themselves more vulnerable over time. So reinforcing with your patients as we go conversationally, helping people understand your back is resilient and strong bending is not dangerous when done properly. And letting people know that, you know, stiffening up can actually increase strain, that letting people know you know your confidence in moving changes how you move. And letting people know this in your daily conversations, through your social media channels, through your reactivation messaging, and really utilizing information like this again across your report of findings and in your movement assessments. If your patient looks like a robot, it might be fear, not pain or weakness, right? So if you're asking a patient to go through sfma, DNS, whatever the testing movement assessments you utilize in your practice, and they just, they look robotic, it's not always due to pain or weakness. So this is what I like to call in all of my businesses, turning over the stone. You see that they're moving, don't make an assumption. Ask right? Turn over the stone. The stone would be they're moving really awkwardly and weird, right? So turn it over. And what do I mean by turn it over? Asking the questions. Can I ask you a question? Are you moving like this because you're scared of getting hurt or because it hurts? And letting them answer and then be able to take what they tell you and then guide them, that's being, in my opinion, a really, really good doctor. And incorporating what we'll call graded exposure. So starting with light tasks, you increasing that load and exposure gradually and normalizing, flexion again within the realms of what's safe and appropriate but helping people understand that really workplace education is there for a reason, but also asking questions, exposure and ultimately really ensuring that they are moving fluidly. Right? It's the fear when you start to see non fluid motion. That's when you start to see stiffening, you see increased load, you see compensation, you see all of these things and you see it all day, every day with your patients. So the question then really becomes, are you having those conversations? Because the big takeaway is that fear, and especially fear of bending can really change how people move. But that effect depends heavily upon their experience. So beliefs matter, movement matters, confidence matters, and you can absolutely make a massively material impact on pretty much all of that. So I loved this study. I think of course there's gonna be more studies like this coming down the pipeline as time goes on because it's just so practical. And before we wrap up, couple shout outs quickly. Shockwave centers of America. $500 off one of their units and a free cart by listening to this podcast. Additionally, if you are looking to build reactivations, patient reactivations into your marketing and growth strategy throughout the rest of 2025 and certainly into 2026, check out what we have going on over at Patient Pilot. You can check it out@the smartchiropractor.com We've made a bunch of new upgrades to Patient Pilot, including reactivation offers. Choosing your own campaign topics at at every single level of the product or service to make it super easy for you to get a good roi. So thank you so much for tuning in and listening to this podcast. If you have not left a rating or review and you would take a moment and do so, I would deeply appreciate it. If you have any feedback, you can always reach out to me, jeff the evidencebasedchiropractor.com Other than that, thank you so much for tuning in. Thank you for being a chiropractor and I will talk to you soon.

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